Information Collection

Division of Independent Review Objective Review Assessment Survey

IC 264344 under ICR 202401-0915-004 · OMB 0915-0212.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1.1 Division of Independent Review Objective Review Assessment Survey	Form and Instruction
Public Burden Statement Screenshot.pdf	Other-Public Burden Statement Screen
Public Burden Statement Screenshot.pdf	Other-Public Burden Statement Screen
1.1 Screenshot Reviewer Instr DIR Review Assessment Survey form 1 - screenshot Reviewer instr.pdf	Form and Instruction
1.1 Screenshot Reviewer Instr DIR Review Assessment Survey form 1 - screenshot Reviewer instr.pdf	Form and Instruction
2 Form Chair Q 1-5 FORM CHAIR Q 1-5.pdf	Form
2 Form Chair Q 1-5 FORM CHAIR Q 1-5.pdf	Form
1 FORM Reviewer Evaluation Q 1- 15 FORM Reviewer Evaluation Q 1- 15.pdf	Form
1 FORM Reviewer Evaluation Q 1- 15 FORM Reviewer Evaluation Q 1- 15.pdf	Form
1.2 FORM Reviewer Evaluation-Field Review Q 1 - 12 FORM Reviewer Evaluation-Field Review Q 1 - 12.pdf	Form and Instruction
1.2 FORM Reviewer Evaluation-Field Review Q 1 - 12 FORM Reviewer Evaluation-Field Review Q 1 - 12.pdf	Form and Instruction
Supporting Statement A - DIR Review Assessment Surve.docx Original Generic Request	IC Document
Supporting Statement A - DIR Review Assessment Surve.docx Original Generic Request	IC Document

IC Title:

Agency IC Tracking Number:

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	1.1	Screenshot Reviewer Instr	DIR Review Assessment Survey form 1 - screenshot Reviewer instr.pdf	Yes	Yes	Fillable Fileable
Form	2	Form Chair Q 1-5	FORM CHAIR Q 1-5.pdf	Yes	Yes	Fillable Fileable
Form	1	FORM Reviewer Evaluation Q 1- 15	FORM Reviewer Evaluation Q 1- 15.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	1.2	FORM Reviewer Evaluation-Field Review Q 1 - 12	FORM Reviewer Evaluation-Field Review Q 1 - 12.pdf	Yes	Yes	Fillable Fileable
Other-Public Burden Statement Screenshot			Public Burden Statement Screenshot.pdf	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 2,300

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	2,300	2,300
Annual IC Time Burden (Hours)	575	575
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Original Generic Request	Supporting Statement A - DIR Review Assessment Surve.docx	01/09/2024

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.